APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination on the basis of race, color. religion national origin, sex, age, disability , or any other status protected by law or regulation. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body WILL be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you may be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

Position for which you are applying:

Date you can start:

Which category do you prefer

If hired, can you furnish proof you are eligible to work in the US?

List languages in which you are fluent:..

Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company:

Have you used any names other than give: If so, please list:

Have you been convicted of a law violation in the past seven years (conviction will not neccessarily bar emplyment);..

Yes

No

Comments

Have you worked for us or an affiliated facility previously?

Yes

No

Facility Name:

Dates employed at above faciility

PLEASE NOTE: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.

Most Recent Employer

Are you currently working for this employer?

Yes

No

If yes, may we contact:

Yes

No

Phone

Employed From:

Employed To:

Job Title:

Supervisor Name:

Duties:

Salary:

Reason for Leaving:

2nd Most Recent Employer:

Phone

Employed From:

Employed To:

Job Title:

Supervisor Name:

Duties:

Salary:

Reason for Leaving:

3rd Most Recent Employer

Phone

Employed From:

Employed To:

Job Title:

Supervisor Name:

Duties:

Salary:

Reason for Leaving:

References:

#1:

#2:

#3:

Education

Please choose the highest grade completed:

High School

Some College

AA or AS

BA or BS

If you have a college degree, please list major:

Name of High School:

Name of College:

Other:

AFFIDAVIT, CONSENT AND RELEASE: Please read each statement carefully before submitting. By clicking submit, you are certifying all the above information is true and complete to the best of your knowledge.I understand that any false information or omission my disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.I understand I may br required to successfully pass a drug-screening examination. I hereby consent to a pre- and /or post-employment drug screen as a condition of employment, if required.I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY A CORPORATE OFFICER OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY A CORPORATE OFFICER AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.This application for employment will remain active for one month.